Five facts about physiotherapy and whiplash

1 Whiplash involves more than neck pain 

Most clinicians associate whiplash with neck pain but patients often present with headaches, dizziness, jaw pain, shoulder pain, arm symptoms, sleep disturbance and psychological distress (Sarkilahti et al 2024). 

These symptoms may reflect concurrent or overlapping conditions following a motor vehicle crash, including headache disorders, concussion, vestibular dysfunction or psychological injury, which can be challenging to differentiate clinically (Belhassen et al 2023). 

Physiotherapists should first triage for serious pathology, ruling out fracture using the Canadian C-Spine Rule (Stiell et al 2001), and assess for neurological involvement. 

Peripheral nerve pathology identified on neurological examination has been reported in approximately 13 per cent of people with whiplash-associated disorders (WAD) and may present as weakness, reduced sensation or reduced reflexes (Fundaun et al 2022). 

Patients may also report radicular symptoms such as burning, shooting or tingling pain (Anarte-Lazo et al 2024, Nijs et al 2023). 

These findings can assist classification according to the Quebec Task Force system, which categorises WAD from Grade 0 to IV based on symptoms and clinical signs (Spitzer et al 1995). 

Most people with WAD are classified as WAD I or II (Bandong et al 2018). 

However, WAD grade alone may not reflect the complexity of a patient’s pain presentation. 

Clinicians should also consider pain phenotype, including whether features of nociplastic pain, such as widespread pain and heightened sensitivity, may be present (Anarte-Lazo et al 2024, Nijs et al 2023). 

2 Not everyone recovers – and you can identify them early after injury 

While many people recover within a few months, around 50 per cent continue to experience symptoms and difficulty returning to their usual activities beyond one year (Kamper et al 2008). 

In a longitudinal follow-up study, 55 per cent of patients reported whiplash symptoms 14 years after a motor vehicle crash, with 14 per cent reporting daily symptoms (Rasmussen et al 2020). 

Prognostic tools can help clinicians identify people who may not recover early after injury. 

Australian guidelines recommend either WhipPredict (Ritchie et al 2015a) or the Short-Form Örebro Musculoskeletal Pain Screening Questionnaire (Linton et al 2011). 

WhipPredict combines age, Neck Disability Index score and hyperarousal symptoms to classify patients as at low, medium or high risk of poor recovery. 

Asking patients about their expectations of recovery may further improve its predictive accuracy (Griffin et al 2022). 

The Short-Form Örebro Musculoskeletal Pain Screening Questionnaire classifies people as low or high risk, with items assessing modifiable risk factors such as anxiety, depression and unhelpful beliefs. 

The tools may help clinicians identify those requiring additional assessment and tailor management accordingly (Rebbeck et al 2023). 

Otherwise, individual factors associated with poor recovery include high initial pain and disability, post-traumatic stress symptoms and poor expectations of recovery (SIRA 2023). 

These factors can be screened using simple validated measures, including a Numerical Rating Scale for pain, the Neck Disability Index for disability, the PCL-5 for post-traumatic stress symptoms and ‘How do you think you will recover?’ for expectations of recovery (SIRA 2023). 

3 Appropriate advice and neck-specific exercise should be provided for most patients 

Patients at low risk should receive first-line management focusing on appropriate advice, remaining active and neck-specific exercise (SIRA 2023). 

Patients should be reassured about recovery, encouraged to continue or gradually resume usual activities and supported to take an active role in their rehabilitation (SIRA 2023). 

Restriction of usual activities should be avoided, while activities may be modified to reduce neck strain and help patients remain active (SIRA 2023). 

Neck-specific exercises should be tailored to the individual and may include range-of-motion, low-load isometric, postural endurance and strengthening exercises (SIRA 2023). 

Exercise prescription should be progressed according to symptoms, function and recovery. 

My Whiplash Navigator provides clinicians and patients with practical, evidence-based resources to support assessment and management of WAD, including guidance on prognosis, exercise and psychological factors (Bandong et al 2019, Ritchie et al 2015b). 

4 Patients at medium or high risk may need targeted assessment and management 

For patients identified as medium or high risk, assessing different domains may help clinicians tailor management strategies more effectively. 

Where clinically indicated, assessment may include pain sensitivity, neuromuscular function, sensorimotor function and psychological factors (SIRA 2023). 

Pain sensitivity can be assessed through light touch, pain pressure thresholds and the ice pain test (cold hyperalgesia), with testing at both local and remote sites to distinguish local from widespread sensitivity (Rebbeck et al 2015, Maxwell & Sterling 2013). 

Neuromuscular assessment may include axioscapular strength and endurance, deep cervical flexor performance via the craniocervical flexion test and/or cervical extensor strength capacity (Jull et al 2008). 

For patients reporting dizziness or unsteadiness, a sensorimotor assessment may include dynamic balance, cervical joint position error, eye–head coordination and oculomotor testing, including smooth pursuit neck torsion and gaze stability (Kristjansson & Treleaven 2009). 

Management will largely be dictated by the risk level and impairment. 

For example, those who are medium or high risk with psychological factors may benefit from StressModex, a six-week physiotherapist-delivered program combining stress inoculation training and exercise. 

StressModex demonstrated clinically meaningful improvements in neck pain-related disability compared with guideline-recommended exercise alone, with benefits maintained at 12-month follow-up (Sterling et al 2019). 

My Whiplash Navigator provides clinicians with practical guidance on assessing these domains, including online training modules for StressModex (Bandong et al 2019, Ritchie et al 2015b). 

5 Referral should be considered for patients who are not improving 

When patients are at medium or high risk of poor recovery and do not respond to usual care, clinicians should consider referral to a specialist, such as a specialist physiotherapist, pain specialist, rehabilitation physician or psychologist (SIRA 2023). 

Complex presentations can be challenging to differentially diagnose and manage, particularly when patients are not recovering as expected. 

Specialists can assist with diagnostic clarification, multidisciplinary management, medication review or coordinated rehabilitation planning. 

Referral should be guided by the patient’s presentation. 

For example, patients with persistent motor control deficits, dizziness or pain sensitivity may benefit from referral to a specialist physiotherapist. 

For patients with moderate to severe symptoms on the DASS-21 or elevated post-traumatic stress symptoms (PCL-5 ≥33), consideration should be given to psychological management and/or psychologically informed care delivered by a physiotherapist trained in this approach (SIRA 2023, Sterling et al 2019). 

The specialist may share the patient with the treating clinician and guide care or temporarily manage the patient before returning them to their original clinician. 

Where appropriate, specialists can facilitate onward referral to other medical specialists through their professional networks. 

>> Marinus du Preez is a PhD candidate at the University of Sydney and physiotherapist working in private practice at Vigour Physiotherapy in Cambridge, New Zealand. Marinus has a special interest in neck pain, headaches, concussion, vestibular conditions and whiplash and is an APA member. 

>> Dr Christopher Papic is a clinical exercise physiologist and a research fellow at RECOVER Injury Research Centre at the University of Queensland, with a particular interest in recovery after traumatic injury. His research focuses on translation and implementation science, including the development and implementation of Australian whiplash clinical guidelines. 

>> Hayden Garner MACP is an APA Titled Musculoskeletal Physiotherapist who is currently a member of the New South Wales Musculoskeletal committee. He works in private practice at Pro Active Physio in Tamworth, New South Wales, with an interest in complex neck and back pain as well as headaches, dizziness and temporomandibular joint pain. 

>> Dr Ana Paula Carvalho-e-Silva is a physiotherapist and a research fellow in the School of Health Sciences at the University of Sydney. Ana Paula’s research focuses on implementation science and musculoskeletal health. She has led the implementation of clinical guidelines for whiplash and contributed to the development of My Whiplash Navigator. 

>> Professor Trudy Rebbeck FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007), researcher and academic at the University of Sydney. Her research focuses on improving health outcomes for people with whiplash and other musculoskeletal conditions, with a strong emphasis on translating research into clinical practice. She has led major whiplash research and guideline initiatives and is internationally recognised for her work in whiplash assessment, prognosis and management. Trudy is an APA Honoured Member.

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